Antithrombotic Therapy Practices in US Hospitals in an Era of Practice Guidelines

Tapson et al established a multicenter database in 38 US hospitals to assess patient characteristics, risk factors, and treatment of those with or at risk of thromboembolic disease. Primary thrombosis prevention was evaluated in those with a diagnosis of atrial fibrillation or requiring total knee or hip replacement or hip fracture repair. Secondary prevention was evaluated in those diagnosed as having acute myocardial infarction, deep vein thrombosis, and pulmonary embolism. The results demonstrate that an unacceptable number of high-risk patients did not receive adequate prophylaxis or treatment. The authors conclude that there are significant opportunities for improving primary and secondary prevention and that it is crucial to overcome potential barriers so that physicians can better protect patients from initial and recurrent thrombotic events.

Prostaglandins play a role in the micturition pathway as they provoke contractions of the urinary bladder. Case reports have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs), via inhibition of prostaglandin synthesis, may increase the risk of acute urinary retention. Verhamme et al conducted a population-based, case-control study among men 45 years and older in the Integrated Primary Care Information database, a general practitioner’s research database, to study this association. The results indicate that current use of NSAIDs doubles the risk of acute urinary retention.

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Accuracy of a Pharmacovigilance Algorithm in Diagnosing Drug Hypersensitivity Reactions

Confirmation of drug hypersensitivity requires sophisticated and potentially dangerous allergy tests to avoid overdiagnosis based on clinical history only. In this study, Benahmed et al evaluated the diagnostic accuracy of a pharmacovigilance algorithm in 677 patients with 1 or more histories suggesting possible drug allergy. The causality assessed according to the algorithm and compared with the final allergy diagnosis was not accurate enough to replace drug allergy testing. However, the authors found 3 parameters linked to drug hypersensitivity, which need to be taken into account when a complete drug allergy diagnosis is not possible: likely causality assessment score, reintroduction in clinical history, and immediate delay.

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Risks of Oral Anticoagulant Therapy With Increasing Age

Oral anticoagulant therapy in elderly patients is a dilemma because of the tendency toward an increased bleeding risk with age. Torn et al studied 4202 patients from a Dutch anticoagulation clinic, who were treated because of mechanical heart valve prostheses, atrial fibrillation, or myocardial infarction, to quantify the risk of bleeding and thromboembolism according to age. The incidence of all adverse events appeared to rise gradually with age. The hazard ratio for bleeding events was 2.7 when age younger than 60 years was compared with age older than 80 years. The hazard ratio for major thromboembolism was 2.2. These findings indicate that it is not feasible to withhold oral anticoagulant therapy from elderly patients.

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Low Heart Rate Variability and the Effect of Depression on Post–Myocardial Infarction Mortality

Both depression and low heart rate variability are associated with an increased risk for mortality after acute myocardial infarction, and depressed patients have lower heart rate variability compared with nondepressed patients. The purpose of this study by Carney et al was to determine whether low heart rate variability, reflecting altered cardiac autonomic function, is responsible for the effect of depression on mortality. Heart rate variability was calculated from 24-hour ambulatory electrocardiograms in 311 depressed patients and 367 nondepressed patients with a recent acute myocardial infarction. The patients were followed up for up to 30 months. Low heart rate variability accounted for approximately 25% of the risk of mortality associated with depression during the follow-up. This finding raises the possibility that treatments that improve both depression and heart rate variability might also improve survival in these patients.